Pediatric feeding disorders among children with parental history of feeding disorders: a distinct group of patients with unique characteristics

To investigate factors associated with pediatric feeding disorders (PFD) among children of parents that reported to have had feeding disorders during their own childhood compared to children with PFD with no history of parental PFD. We retrospectively reviewed the medical records of children diagnosed with PFD according to the recent WHO-based definition. The demographic and clinical characteristics of children with PFD with a parental history of PFD were compared to those of children with a PFD with no history of parental PFD. Included were 231 children with PFD (median [interquartile range] age 10 months [5.5–29] at diagnosis, 58% boys) of whom 133 children had parents without PFD and 98 children had parents with PFD. Unexpectedly, children of parents without PFD had a higher rate of low birth weight (28% vs. 19%, respectively, p = 0.007), more delivery complications (10% vs. 2%, p = 0.006), more hospitalizations (33% vs. 17%, p = 0.004), more prescription medications (27% vs. 18%, p = 0.05), and a higher percent of gastrostomy tube use (6% vs. 0, p = 0.02). Moreover, more parents with PFD had academic background compared with parents without PFD (72% vs. 59%, p = 0.05). There were no significant group differences in sex, history of breastfeeding, parental marital status, or type of the child’s feeding disorder. Conclusion: PFD among children with a parental history of PFD comprise a distinct group of patients with unique characteristics and outcomes. Since parental feeding history may explain their child’s PFD in highly differing ways, such information may help in devising a specific family-based and multidisciplinary treatment plan for those children. What is Known: • Pediatric feeding disorder (PFD) is relatively common and its prevalence is increasing. • Information on an association between parental PFD and their child’s feeding disorder is limited. What is New: • PFD among children with a parental history of PFD comprise a distinct group of patients with various characteristics and outcomes. • The parents’ feeding history during childhood may provide important clues to their child’s PFD. What is Known: • Pediatric feeding disorder (PFD) is relatively common and its prevalence is increasing. • Information on an association between parental PFD and their child’s feeding disorder is limited. What is New: • PFD among children with a parental history of PFD comprise a distinct group of patients with various characteristics and outcomes. • The parents’ feeding history during childhood may provide important clues to their child’s PFD.


Introduction
Pediatric feeding disorders (PFD) comprise a heterogeneous group of conditions with no universally accepted classification. They may include, but are not limited to, poor appetite, food selectivity, food refusal, and delayed or absent development of feeding skills which may or may not be accompanied by inappropriate growth [1]. PFD is a relatively common clinical diagnosis with increasing prevalence [2][3][4]. Manikam and Perman documented a prevalence of 25% of children in the general population and up to 80% of children with developmental disabilities over 2 decades ago [2]. Up to 20% of parents are reportedly concerned about their child's feeding behavior, resulting in considerable numbers who seek professional help [3].
A unifying diagnostic definition of PFD was recently proposed by a panel of experts in the care of children with feeding disorders [5]. Their proposed consensus definition and conceptual framework were based upon the framework of the World Health Organization (WHO) International Classification of Functioning, Disability, and Health [6]. That WHO framework defines functioning as an umbrella term referring to all body functions and defines disability as an umbrella term covering impairment (a problem in body function or structure), activity limitation (difficulty encountered in executing a task or action), and restricted participation (problems in involvement in life situations) [6]. According to that definition, PFD comprise impaired oral intake that is not age-appropriate and one that is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. This classification system describes the impact of PFD on a child's physical, social, emotional, and cognitive functions, as well as on the caregiver-child relationship, and allows better characterization of heterogeneous populations in order to include all relevant disciplines in the treatment protocol [5].
Factors associated with the child, the caregiver, and the feeding environment can adversely affect the acquisition of feeding skills and ultimately contribute to and maintain PFD [7,8]. We had recently shown that low socioeconomic position, the absence of breastfeeding, and low birth weight were significantly more frequent in children with PFD [9]. However, the effect of the parent's own eating behavior on the development of their child's eating habits has not been tested.
It has been shown that parental eating disorders may impact a child's feeding and eating patterns, but the parental eating disorders reported in previous studies were mainly related to disorders during adolescence or adult life and mostly defined according to the classification of anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) [10]. Moreover, several diagnostic methods and criteria have been used inconsistently [10]. The data on the relationship between children's PFD and a parental history of a PFD are limited. Therefore, the aim of this study was to investigate factors associated with PFD among children of parents that reported having had PFD compared to children with PFD with no history of parental PFD and to assess their relation to a specific feeding disorder type according to the recent WHO-based definition.

Patient population and study design
The sociodemographic and clinical data of all infants and children with PFD aged 0 to 60 months that were treated in the multidisciplinary feeding clinic of the Institute of Pediatric Gastroenterology, Hepatology, and Nutrition at Dana-Dwek Children's Hospital, Tel Aviv Medical Center from 2016 to 2020 were collected prospectively. Included in the present study were the infants and children aged 0 to 36 months who had been referred from January 2018 to January 2020 to the Feeding Disorder Clinic with a clinical diagnosis of PFD and documentation of parental PFD. Excluded were 56 subjects who were seen at the clinic in whom the diagnosis of a PFD was ruled out according to the new consensus definition (see below), as well as 59 patients with missing essential data. The study protocol was approved by the institutional review board ("Helsinki") of the medical center (reference number -TLV-0590-20). Informed consent of the participants was waived since the data retrieved from the medical records were anonymized. The data were handled in accordance with the Principles of Good Clinical Practice.

Data collection
The Feeding Disorder Clinic team includes a gastroenterologist, a dietitian, speech therapists, and a psychologist. The information in the medical files contains both self-reported patient/parental information and the team's notes on diagnoses, management, and surveillance. All hospital medical records are electronic, with additional access to the individual's health maintenance organization laboratory data. The information retrieved from the subjects' medical files included the following:

Definition of study variables
Socioeconomic status (SES) was determined by the patient's home address according to the Israel Central Bureau of Statistics' Characterization and Classification of Statistical Areas within Municipalities and Local Councils by the Socio-Economic Level of the Population 2015 [11]. The SES was scored by clusters of localities of residence ranging from 1 to 10, with 1 being the lowest rating and 10 the highest. The SES index is an adjusted calculation of 14 variables that measure social and economic levels in the domains of demographics, education, standard of living, and employment (ranging from the lowest [− 2.797] to the highest [2.590]). Academic background was defined according to the sociodemographic status of parents that completed tertiary education. Low birth weight (LBW) was defined as a BW below 2500 g. Pregnancy complication was defined as any high-risk pregnancy due to maternal or fetal problems (e.g., gestational diabetes mellitus, preeclampsia, cholestasis, intrauterine growth retardation, multiple pregnancy). Delivery complication was defined by the presence of maternal fever, premature rupture of membrane, shoulder dystocia, or perinatal asphyxia. PFD was diagnosed according to the consensus group definition as a disturbance in oral intake of nutrients inappropriate for age lasting for at least 2 weeks and an absence of cognitive processes consistent with eating disorders and pattern of oral intake not due to a lack of food or to being incongruent with cultural norms [5]. The type of the child's and the parents' feeding disorder was defined by the clinical team based upon the information obtained from the patients' medical files. The authors retrospectively reviewed those files and divided the feeding disorder types into a nutritional disorder (any case of malnutrition, specific nutrient deficiency, or reliance upon oral supplements to sustain nutrition), feeding skill dysfunction (use of modified feeding strategies, position, or food texture), medical (any medical conditions that could interfere with normal age-appropriate eating practice, e.g., cleft palate and absent swallowing reflex), and psychosocial dysfunction (any case of avoidance behaviors when being fed or inappropriate caregiver management of the child's feeding). The code of the predominant type (nutritional, feeding skill, medical, and psychosocial dysfunction) was used in cases of an overlap of PFD manifestations. The presence of any history of parental PFD was derived from the interview by the clinical team conducted during the first encounter as recorded in the child's medical file. The diagnosis of PFD among parents was also based upon the above consensus guidelines [5]. There was disagreement between the team in fewer than 10% of the cases, and the dominant type was defined as the one that received the most votes.

Statistical analyses
The data were analyzed with the Statistical Package for the Social Sciences software version 27 (SPSS Inc., Chicago, IL). All statistical tests were two-sided. The Kolmogorov-Smirnov test and the Shapiro-Wilk test were applied to assess the normality of continuous data. The data are expressed as means ± standard deviation (SD) for normally distributed variables and median and interquartile range (IQR) for skewed distribution. Pearson's chi-square test or Fisher's exact test was performed to compare the distribution of categorical variables between children with PFD of parents with PFD and children with PFD of parents without PFD. An independent sample t-test or an independent sample Mann-Whitney was performed to compare between groups for continuous variables with a normal or skewed distribution, as appropriate. The Kruskal-Wallis test was used to compare four types of feeding disorders. A p value < 0.05 was considered significant. Table 1 lists the demographic and clinical data of the infants and toddlers with PFD. The cohort comprised 231 patients of whom 134 (58%) were males and who had a median age of 17 (interquartile range [IQR] 10-34) months. According to the consensus PFD definition, the disturbance in oral intake was predominantly related to a nutritional dysfunction in 111 children (48%), to feeding skill dysfunction in 75 (32.6%), to a medical condition in 36 (15.6%), and to a psychological dysfunction in 9 (3.8%, Fig. 1). Sixteen children (7%) were treated with cyproheptadine and 37 (16%) with proton pump inhibitors. Eight (3.4%) children received nutritional supplementation via gastrostomy.

Factors associated with PFD children of parents with PFD
A total of 98 (42.5%) children had parents who reported to have PFD, and 133 children had parents who denied ever having PFD. A comparison between the former and latter children revealed significant perinatal and clinical differences. More children in the latter group had a history of delivery complications compared to the former group (14 [ There were also sociodemographic differences between the groups. The number of parents with an academic background was higher in the families of parents with a history of PFD compared to families of parents without a history of PFD (72% versus 59%, respectively, p = 0.05). There was no group difference in age, sex, gestational age, low birth weight, breastfeeding or bottle feeding, age of complementary food introduction, background diseases, documented allergy to food, socioeconomic position, marital status of the parents, or in the child's PFD subtype (Table 3).

Discussion
We investigated the characteristics of children with PFD whose parents reported to have had a feeding disorder during their own childhood. We applied the recently proposed diagnostic term "pediatric feeding disorder" for unifying the medical, nutritional, feeding skills, and psychological concerns associated with the disorder. Our results demonstrated clinical and sociodemographic differences between children with a PFD diagnosis whose parents had a history of a childhood feeding disorder and those who did not. Children of parents without PFD had a higher rate of LBW, more delivery complications, more hospitalizations, and a higher percentage of gastrostomy tubes and prescription medications. Moreover, more parents with PFD had an academic background compared with parents without PFD.
The influence of parental feeding history on children likely stems from a complex interplay between environmental and genetic factors [12]. Parental PFD may impact parent-child interactions, child socioemotional functioning, and eatingrelated behavior and patterns. Parental food habits and feeding strategies were reportedly the most dominant determinants of a child's eating behavior and food choices [13]. The association between parental eating disorder (AN, BN, and BED) and their children's feeding practices is well documented [10]. Torgersen et al. found that maternal eating disorders may influence the child's diet (vegetarian, homemade, or commercial) at as early as 6 months of age. Those authors suggested that dietary patterns in infancy may set the foundation for lifelong eating patterns and possible eating problems [14]. Brytek-Matera et al. showed that both the maternal feeding style and core behavioral features of eating disorders were associated with avoidant/restrictive food intake disorder symptoms among 2-to 10-year-old children [15].
There are no published data on the association between a parental history of PFD and their children's feeding disorders. We considered that having sustained PFD themselves may affect parents' subsequent attitude toward food and eating patterns in several ways. First, specific PFD may persist into adulthood. Several studies have suggested that picky eating, which is a common disorder during childhood, is often a chronic problem that can similarly continue into adulthood [16,17]. Parental selective eating could be  [18]. Another study used the modified version of the Comprehensive Feeding Practices Questionnaire to measure recollections of parental feeding practices in childhood and to determine a relationship between those practices recollected by adults with their current food choices. Those authors found that childhood experiences might favor certain dietary patterns in adulthood [19]. Finally, genetic factors may also play a role, with some studies having shown high heritability of eating behavior traits, including appetite [20,21], food acceptance [22], and taste predisposition [23].
We also found that more parents with a history of PFD had an academic background compared with parents without a history of PFD. This is in agreement with high levels of academic performance, perfectionism, and achievementoriented nature being frequently reported characteristics of individuals with eating disorders [24,25]. The association between parental educational level and offspring eating disorder has been already described as well. A large Swedish population cohort study has shown that the incidence of eating disorders in females was independently predicted by higher educational levels among the father, mother, and maternal grandparents [26]. Another cohort study from Denmark found that higher parental SES was associated with increased risk of eating disorders in offspring, particularly AN [27]. Higher parental and grandparental education and higher school grades reportedly may increase the risk of hospitalization for eating disorders in female offspring, possibly because of high internal and external demands [28].
The lesser effects of clinical background variables (delivery complications, hospitalizations, and treatment with prescription medications) in children of PFD parents suggest that the presence of a history of parental feeding disorder may be the dominant factor which may lead to different subtypes of their child's PFD development. Interestingly, the presence of parental PFD was not associated with any predominant subtype of PFD in their child, supporting the notion that PFD may have various expressions in the next generation and highlight the need for a multidisciplinary approach in order to better understand this familial tendency. This is one of the first studies to provide clinically based evidence for the association between parental PFD and their children's PFD according to the recent consensus WHObased definition. This study is limited by its retrospective nature and the relatively small sample number. Moreover, the parental PFD diagnosis was made based upon selfreporting which could lead to associated recall bias or inaccuracy due to parental memory. Some degree of incompatibility between clinical diagnosis and the formal PFD new definition may be anticipated. However, since the diagnosis of PFD was made by a multidisciplinary team comprised of a pediatric gastroenterologist, dietician, speech therapist, and psychologist, we believe that inaccuracies in the diagnosis of PFD and its subtypes were held to a minimum. Lastly, the patient cohort accessed care at a subspecialty clinic and they may not represent the broader pediatric population. However, our hospital is a tertiary care medical center which we believe represents the general pediatric population.
In conclusion, the findings of our study demonstrate that perinatal and clinical factors are more significant in PFD children of parents without a history of PFD, and support the notion that a history of parental PFD may in and of itself be a significant factor in the child's PFD development. A multidisciplinary therapeutic approach that includes speech and emotional therapist is essential in order to better characterize this family tendency. Parental feeding history is a relevant and important factor which should be addressed by the treating team. Further longitudinal studies with a uniform diagnosis of parental PFD as well as ongoing parental feeding disorder are needed in order to better assess the prevalence of parental feeding disorder among children with PFD and explore a causative relationship between them.